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Multi-Specialty Practice

  1. Default Multi-Specialty Practice
    Medical Coding Books
    I have been having an ongoing problem getting claims paid due to the fact that we are a multi-specialty practice. When a patient is in the 90-day global with one of our specialists and also sees her PCP who is part of our group; the insurance denies the PCP visit stating it is included in the surgery global. Every conversation I have with the insurance adjustor has them saying I have to append modifier 24 to the claim if I want it to pay. Modifier 24 clearly states E&M by the same physician during the post-op period. Am I missing something here. Is there a modifier that is appropriate for a patient being seen by a different physician; different specialty, in the same practice within the 90-day global?

  2. #2
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    Kae, would the insurance company happen to be Humana? They pay no attention to the specialty of the doctor, only the tax ID#. We had the same problem when the hematologist visited a pregnant patient who was hypercoaguable - they denied his visit as part of the global OB package! When I called and spoke to the appeals person, he told me that he knows modifier 24 isn't correct coding in these instances, but is the only way to get their system to pay the claims that should be paid. So now, even though not correct, if these different specialties' claims deny, our billers/follow up people have them reopen with modifier 24. The coders don't put them on the claim to begin with.

    I feel your pain - and you are correct, the 24 is for the same physician (or same specialty, same group) during post op for unrelated visits.
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

  3. Default
    Thanks for the info. No the insurance is not Humana; just the "Blues". I just have a very hard time appending a modifier that I know is incorrect.

  4. #4
    Location
    Sioux Falls South Dakota
    Posts
    358
    Default
    I know how you feel. Our state's Medicaid will not allow us to use modifier 59 - their instructions are to use modifier 51. We know it's wrong, but what can we do?
    Lucinda (Cindy) McGarry, CPC-P
    Applications Specialist
    Avera Health Plans
    Education Office Sioux Falls SD Local Chapter
    Past President Sioux Falls SD Local Chapter

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